NHS Equality Delivery System 2022 EDS Report North West Ambulance Service NHS Trust 2022/23 Review Year

Equality Delivery System for the NHS

The EDS is an improvement tool for patients, staff and leaders of the NHS. It supports NHS organisations in England – in active conversations with patients, public, staff, staff networks, community groups and trade unions – to review and develop their approach in addressing health inequalities through three domains: Services, Workforce and Leadership. It is driven by data, evidence, engagement and insight. The EDS Report is designed to give an overview of the organisation’s most recent EDS implementation and grade.

Organisational Details

Name of Organisation: North West Ambulance Service NHS Trust

Name of Integrated Care System: Lancashire & South Cumbria ICB

Organisation Board Sponsor/Lead: Lisa Ward, Director of People

EDS Lead: Usman Nawaz Head of Inclusion & Engagement Wasim Mir Equality, Diversity & Inclusion Advisor

EDS engagement date(s): December 2023 – February 2024

At what level has this been completed?

Individual organisation: North West Ambulance Service
Partnership* (two or more organisations), Integrated Care System-wide*: ICBs were not in a position to support with the assessment this year and the NHS EDI Team was advised of this.

Date completed: Domain 2&3 – 05/12/2023 Domain 1 – 20/02/2024

Month and year published: February 2024

Date authorised: 23/02/2024

Domain 1: Commissioned or provided services

Outcome 1A: Patients (service users) have required levels of access to the service

Evidence for this outcome was provided by the Integrated Contact Centre Team. A summary of the evidence is presented below with the detailed version available on pages 4 – 5 of the Evidence Pack.

The Trust utilises a nationally approved and licenced triage tool, NHS Pathways, to assess all patients who access 111 or 999 provision.

The Trust utilises the British Sign Language 999 app, this allows those patients who have hearing disorders the ability to rapidly and effectively access our service. We also use a text relay service for some patients, so they can utilise text to place a 999 call and receive and appropriate response with our service.

The Trust monitors how individuals are accessing services through the capturing of data through Electronic Patient Records (EPR).

The Integrated Contact Centres ensure those with protected characteristics are able to access services through the provision of appropriate communication tools to support those who may struggle with verbal communication.

Wherever possible and practicable, the Trust attempts to utilise options other than telephony in accessing services, this has been implemented nationally with 111 online and locally with the provision of online booking for Patient Transport Services (PTS). And are continually developed to ensure that clinical bias is removed, our triage systems, whilst nationally mandated, consider any impact on those with protected characteristics.

The size and scope of our service does present a challenge when ensuring that our service caters to a large geographical area and many individuals with protected characteristics. Changes to such a complex system can often introduce unforeseen risks and challenges which must be addressed in real-time.

Challenges to data collection has been evident in reviewing the dip sample of Face to Face access. There is a lack of consistent recording of patient ethnicity that poses a challenge to collating data around inequalities of access. Further review of options and engagement with front-line staff to understand the root causes and explore alternative methods of gathering data should be undertaken.

Rating: 2

Owner (Dept/Lead): Integrated Contact Centre Team

Outcome 1B: Individual patients (service users) health needs are met

Evidence for this outcome was provided by the Patient Experience Team. A summary of the evidence is presented below with the detailed version available on pages 6-10 of the Evidence Pack.

The Trust actively engages with patients with protected characteristics and other groups at risk of health inequalities about their experience of the service through our annual engagement plans. Groups worked with in relation to the 999 service including patients from the following protected characteristics: disability, age, gender, race/religion. Trust has worked with disability groups from the deaf community to support them accessing the 999 service which has influenced the roll out of the Insight App across the 999 service.

The Trust has also worked closely with learning disability groups on producing new easy read / accessible 999 leaflets.

In addition, the Trust has engaged with the deaf community regarding accessibility to services i.e. BSL Emergency Video Relay Service to ensure they are aware and understand the aids that are available to them when accessing the emergency service.
The Trust hosts annual community listening events, held in each of the five geographical areas covered, and attend numerous events across the North West to talk and listen to patient experiences. These include Health Melas, PRIDE events, Windrush, disability awareness days and both large and small community events.

The Trust targets attendance from race/religion, disability and mixed age/gender groups, actively selecting venues used and known by the community. Also review venues for accessibility and look at the communities contained within the area, to ensure that every opportunity to engage with groups representing the protected characteristics is taken.
At every event we host, the Trust seeks to educate attendees about our 999 service through lightning talks, with support from frontline colleagues and various literature on how to access and use our services appropriately, which are also accessible in alternative formats.

The insights from 999 calls data are used to identify the most frequent types of calls /reasons for using the emergency service. This identified calls relating to falls as one of the top reasons for the corresponding period last year. Whilst receiving high numbers of fall related calls across the NW, it was identified that these were highest in Greater Manchester and relating to older patients, both male and female. As a result, the Trust has focused on producing hard copy leaflets, and physical adverts in GM newspapers together with face-to-face community events to target people who are generally offline and hard to reach via social media and digital platforms.

Our Patient and Public Panel offers involvement in many ways, both virtual and face to face, in and out traditional office hours, at different venues and in ways that suit the lifestyles and needs of protected groups as well as community groups identified as seldom heard. The Trust also works with local Healthwatch and other healthcare providers to improve outcomes for people with a protected characteristic and other groups at risk of health inequalities.

The challenges encountered have been ensuring that representation on the panel mirrors, as closely as possible, the diverse communities, by age, gender, ethnicity and disability. To overcome these challenges, there is regular review and cleanse of the PPP membership database, as well continuous promotion, and recruitment. There is also an action plan in place to help achieve the trust diversity targets.

Rating: 2

Owner (Dept/Lead): Patient Experience Team

Outcome 1C: When patients (service users) use the service, they are free from harm

Evidence for this outcome was provided by the Patient Safety Team/F2SU Guardian. A summary of the evidence is presented below with the detailed version available on pages 11-12 of the Evidence Pack.
Data from the Datix system April 2022 to March 2023 shows:

• 6168 total Datix events
• 313 Ethnicity data (5855 blank fields)
• 314 Gender data (5854 blank fields)
• 28 Disability (6140 blanks)

New Patient Safety Incident Response Framework is being embedded which takes an increasingly patient-centred approach to patient safety event reviews.

PSIRF Policy has section on Healthcare Inequalities and notes that our safety improvement work will utilise data around our populations and patient safety data to identify variations of inequality to ensure it is considered as part of future development process.

Developing safety improvement plans for thematic reviews for PSIRF local and national priorities, which includes maternity and mental health.

NWAS has engaged 3 Patient Safety Partners (PSPs), a requirement of the 2019 NHS Patient Safety Strategy. The PSPs will advocate for the needs of patients and work alongside to do so on patient safety agenda.

NWAS is currently working with a number of prison services to address healthcare inequalities around the prison population and difficulties of ambulance service access.
Undertaking a thematic analysis of patient harm over the winter period (December 2023 – January 2024) with a focus on healthcare inequalities such as frailty and nursing home residents, mental health patient calls etc.

Establishment of Regional Clinical Learning & Improvement Group, a NWAS-platform for sharing learning and improvement relating to patient safety, which allows the discussions of cases relating to health inequalities where a risk-based approach to learning and improvement is taken, seeking subject matter expertise.

The needs of protected characteristics groups been considered and this is demonstrated through the Trust’s Freedom 2 Speak Up (F2SU) guardians who have continued to embed the trust culture of openness and transparency, encouraging staff to raise any concerns they have regarding patient care. Since April 2023 the trust has received 129 concerns which is a 29% rise on the previous year and of that 26 concerns relate to patient safety.

Rating: 1

Outcome 1D: Patients (service users) report positive experiences of the service

Evidence for this outcome was provided by the Patient Public Panel (PPP) Team. A summary of the evidence is presented below with the detailed version available on pages 13-15 of the Evidence Pack.

Engagement with patients for them to provide feedback is undertaken via a variety of channels; bespoke patient experience surveys by service line, national friends and family test question (FFT) survey for the 999 service (see and treat), community and focus group engagements, Patient and Public Panel and our regional annual community listening events.
Providing AED training. Since this training session, the trust has had a considerable amount of interest from other community groups and organisations to deliver similar training. The trust has visited the African Caribbean Care group, a 50+ community group, Deaf village, and Thornton Medical Practice PPG to deliver CPR/AED training. Also have been involved with targeted engagement work in the Cheshire and Merseyside area where have contacted community groups in to offer opportunity of booking a training session, to which have received an overwhelming number of requests.

The Trust captures and shares filmed patient and staff stories to increase understanding of the needs of patients with protected characteristics as well as identify and deliver improvements. An example is production of a staff story on use of the Language Line App when it was being piloted. This was based on a staff member’s positive experience of using the app which enabled them to communicate effectively with a female patient of mixed ethnic origin with a pregnancy related condition who did not speak English.

From the 999 surveys in 2022/23 3.2% of respondents were from Black and minority ethnic communities, (Black, dual heritage, Bangladeshi, Indian and Pakistani) of which 89.7% rated their overall experience of the service as ‘very good/good’ and 92.3% indicating that they were ‘cared for appropriately, with dignity compassion and respect’.

10.2% of respondents reported hearing impairment and of this group, 88.1% rated their overall experience of the service as ‘very good/good’ and 93.7% indicating that they were ‘cared for appropriately, with dignity compassion and respect’. Patient demographic stats from the April 2023 shows that on average across all survey returns, 40.1% of respondents had mobility impairment, with 19.2% having more than one impairment. Analysis also indicated that on average, 5.7% were from Black and minority ethnic communities.

One of the main challenges the Trusts faces is ensuring that sufficient survey responses obtained that are representative of different user groups and communities (randomly select minimum of 1% of service users to invite to complete patient experience survey, hence no control over who is surveyed). Of the returns since Apr 2023, from randomly sent 999 PE surveys, 4.8% were from Black and minority ethnic communities, with 17.4% having hearing impairment, 3.1% learning disability and 5.4% visual impairment, with mobility impairment highest at 34.1%.

The needs of protected characteristics groups are a key consideration and the trust has a diversity action plan in place which includes our area of focus and how aim to engage and recruit panel members from ethnic minority communities as well as maintain youth involvement. The plan outlines which protected groups the trust will engage with and recruit from which are race/culture and youth, e.g. the Chinese community, Jewish community and the Somalian community and how aim to achieve this through attendance at events such as freshers’ fayres.

The Trust listens to the experiences of PPP members who have used services and share their experience across the Trust. Some Panel members are also Patient Safety Partners for the Trust and their experiences help to improve the patient safety culture across the Trust and to encourage staff members to speak up about any concerns they have which in turn enables better patient experiences.

Rating: 2

Domain 2: Workforce health and well-being

Outcome 2A: When at work, staff are provided with support to manage obesity, diabetes, asthma, COPD and mental health conditions

Evidence for this outcome was provided by the HR Business Partnering Team. A summary of the evidence is presented below with the detailed version available on pages 4 – 7 of the Evidence Pack.

For most staff, initial support for obesity, diabetes, asthma, COPD and mental health conditions often comes via the work health assessment undertaken by Occupational Health. The OH service advises managers in relation to any declared health conditions that may affect the individual’s ability to carry out their role safely and effectively. Where the condition is not detrimental to the individual’s safety to conduct the role or the ability to fulfil the role requirements, we are advised on what reasonable adjustments we may need to consider to support the staff member.

Obesity: The trust’s wellbeing offer provides signposting to a range of information and services relating to obesity i.e. fitness, heart health and healthy eating. The OH service also provides advice and guidance to staff in relation with obesity.
We have reviewed our process for work place health assessments in relation weight/BMI. Weight testing is not routinely undertaken for Trust roles, except for helicopter paramedics for safety reasons. The only other instances where specific weight is assessed, is in order to provide advice and support to control room staff to identify requirements where an alternative chair may be more appropriate.

Diabetes: Staff who are diabetic are provided with access to storage facilities for medication and can take time to take/administer medication and attend medical appointments. Support and advice is also provided on healthier lifestyle changes to help begin to reverse or ward off the possibility of type 2 diabetes due to diet.

Support to manage Asthma/COPD: Staff with asthma and COPD conditions are supported with access to OH services, time to attend medical appointments and through the wellbeing offer. During the Covid period, the trust took extra care to ensure appropriate provisions were made for colleagues who were more susceptible to the virus. There was a recognition during the pandemic that some staff groups and those with particular protected characteristics groups may have a higher level of risk/susceptibility to certain Covid strains. These individuals were additional supported covered with an individual risk assessment and adjustments to mitigate risk which may have involved isolation or home working etc.

Support for mental health conditions: We recognise that mental health is our biggest absence driver. In the 2022/23, over 1700 session of counselling services and complex counselling services (EMDR/CBT) were accessed by staff. We developed training for all managers to understand the management support required for staff with mental health conditions or those who are suffering with stress. We also recently introduced better access and a process for those staff with potential neurodivergent conditions such as autism and ADHD.

Across all the conditions, it was noted that there was no data available in relation to the monitoring of protected characteristics data with regards the staff who are accessing the services. The rating agreed for this outcome is reflective of this and actions were noted to seek this information for subsequent assessments.

Rating: 2

Owner (Dept/Lead): HRBP

Outcome 2B: When at work, staff are free from abuse, harassment, bullying and physical violence from any source

Evidence for this outcome was provided by the Violence Prevention & Reduction Group. A summary of the evidence is presented below with the detailed version available on page 8 of the Evidence Pack.

Reported incidents are aggregated and collated to inform dashboards which are presented at the Health, Safety, Security sub-committee and the Violence Prevention and Reduction Group (VPRG) which meets every two months. Progress towards meeting the NHS Violence prevention security standards has been positive – currently 74% compliant and this has been peer reviewed by other ambulance trusts in the sector.

The annual violence and aggression deep dive includes a review of the NHS Staff Survey results for the trust against internal incident reporting, with consideration of the data related to the protected characteristics groups. In the last year, the VPRG has started to engage with Race Equality Network and Women’s Network to identify areas of focus.

Two initiatives that will support the outcome further are in early stages or due to be started:

• Sexual safety in the workplace group initiated.
• Suicide prevention for staff particularly in ICCs.

The score reflects that the equalities related work in this area is at an early stage. Currently there are issues data quality in relation to incidents as protected groups are not easily identifiable from the reporting systems as currently set up. This was noted as an action for improvement.

Rating: 1

Owner (Dept/Leader): VPRG

Outcome 2C: Staff have access to independent support and advice when suffering from stress, abuse, bullying harassment and physical violence from any source

Evidence for this outcome was provided by the HR Business Partnering Team. A summary of the evidence is presented below with the detailed version available on pages 9 – 12 of the Evidence Pack.

Staff have access to a number of Trade Unions (TUs) who can provide independent support to staff relating to stress, abuse, bullying, harassment, and physical violence. There are also well-established Freedom to Speak Up channels available to staff. This includes a specialised team with a newly appointed lead and guardians for independent reporting and investigation of issues.

Stress: The Attendance Improvement Team have developed and delivered a number of resources over the last 12 months to help proactively combat stress to avoid absence, and also reactive resources in cases where stress may have already caused absence. Examples include launching a new wellbeing conversation template, and relaunching a refined Stress Risk Assessment process used in cases of workplace stress being reported.
It was noted that there was no data available in relation to the monitoring of protected characteristics data with regards the staff who are accessing services. The rating agreed for this outcome is reflective of this and actions were noted to seek this information for subsequent assessments.

Bullying and Harassment: In the last year, there has been a big focus on sexual safety in the trust. The HR leadership team have proactively engaged in a reflective learning session which has resulted in a sexual safety charter and commitment being developed and beginning to be rolled out across the organisation, led by the Director for People. This ensures robust processes for the reporting of sexual misconduct and a clear procedure to be followed when instances are reported to act quickly and appropriately.
The role of Staff Networks is important in being an avenue for support for individuals who may experience bullying and harassment. The Networks provide a voice and a listening ear to address issues and signpost to other support channels. The HRBP team will be building on engagement with Networks to act on specific issues raised.

Violence and Aggression: Whilst cases involving violence and aggression tend to be fairly low in relative terms, we may begin to get a more accurate representation across the next year, with introduction of a refreshed reporting and monitoring process.
Where there are specific instances of violence and aggression relating from patients/public towards staff, we share information with our health and safety team to evaluate the safeguarding of staff providing front line health care and put measures in place to improve their safety. The HRBP team also support the Violence Prevention and Reduction Group comprising of staff from a wide range of departments across the trust including operations, contact centres, communications, HR, H&S, training as well as a representation from TU colleagues.

Rating: 2

Owner (Dept/Lead): HRBP

Outcome 2D: Staff recommend the organisation as a place to work and receive treatment

Evidence for this outcome was provided by the Engagement Team. A summary of the evidence is presented below with the detailed version available on pages 13 – 16 of the Evidence Pack.

Results from the 2022 Staff Survey showed that overall, 46% of staff would recommend NWAS as a place to work. Responses from BME staff were positive (50%), but disabled and LGBT+ staff responses were below the organisational average.

Looking at exit interview data over the last year, the reasons given by staff who are BME / have declared a disability / LGBT+ are broadly comparable between each demographic with ‘improved work life balance’, ‘higher pay’ and ‘career progression’ persistently ranking in the top three. However, ‘Black or Black British’ colleagues have indicated ‘Harassment / Discrimination’ as a reason for leaving, which is not in the top three reasons for any other demographic.

In the Staff Survey, 61% of staff said they would be happy with the standard of care provided by NWAS if a friend or relative needed treatment. The responses from BME and LGBT+ are in line with the overall average, but only 56% of staff who declared a disability felt this way.

While the Staff Survey provides rich data in this regard, it was recognised that there was a need to use this evidence base to demonstrate positive changes in the organisation going forward.

Rating: 1

Owner (Dept/Leader): Engagement Team

Domain 3: Inclusive leadership

Outcome 3A: Board members, system leaders (Band 9 and VSM) and those with line management responsibilities routinely demonstrate their understanding of, and commitment to, equality and health inequalities

Evidence for this outcome was provided by the Corporate Governance Team Engagement Team. A summary of the evidence is presented below with the detailed version available on pages 17 – 21 of the Evidence Pack.

The Board, together with VSM leaders are committed to leading, promoting and demonstrating their commitment to improving equality and health inequalities outcomes across the Trust. This is demonstrated through partnership working by engaging with ICBs as part of the system working, Healthwatch and other provider trusts. There are clear links between staff experience and patient experience, so it is vital for the Board to show visible leadership on matters of diversity. Part of this commitment is for the Board of Directors to develop their understanding of the barriers facing different groups of patients and staff through Patient and Staff Stories at Board meetings.

All Board members, system leaders and staff with line management responsibilities continue to support a large number of events and programmes to promote and raise awareness of relating to equality and health inequalities.

The Trust Strategy (2022-2025) recognises that the trusts priorities continue to be guided by national legislation and recommendations. These priorities include closer working between health and social care at a local level, reducing delays and longs waiting, improving access to primary care (GP and community services) and mental health services, managing health and inequalities within populations and staff health and wellbeing.

Engagement with Staff Networks: Directors continued in their Executive Champion roles aligned with Networks or particular equality strands. Champions are accountable for supporting network objectives, acting as allies and advocates and for bringing the perspective of their equality strands to ELC debate and decision making.

Board development: The Board of Directors receive regular updates relating to workforce equality, include race, gender and disability. The e-learning assessment relating to Equality, Diversity and Human Rights is also undertaken by Board members. Board Development sessions during 2022/23 focussed on EDI (WRES, WDES/Gender Pay Gap) and health and wellbeing. The 2023/24 Board Development programme continues to support the EDI agenda through collaborative discussion and further learning.
EDI and other pertinent areas such as sexual safety, promoting anti-racism and delivery of actions set out within the Board EDI priorities continue to be a focus within objectives for Directors. Assurance reports relating to regulatory and statutory EDI Workforce Reporting and progress against targets, and the EDI Annual Report and Health and Wellbeing Report Annual Report are submitted to the Resources Committee and Board of Directors. Progress against these targets is included with the EDI Annual Report 2022/23.

Rating: 2

Owner (Dept/Lead): Corporate Governance Team

Outcome 3B: Board / Committee papers (including minutes) identify equality and health inequalities related impacts and risks and how they will be mitigated and managed

Evidence for this outcome was provided by the Corporate Governance Team Engagement Team. A summary of the evidence is presented below with the detailed version available on pages 22 – 23 of the Evidence Pack.
Identifying and assessing equality related impacts are a key focus of the reporting processes to the Board of Directors, Committees and SubCommittees. Specifically, reports/proposals are expected to highlight whether any particular staff or patient groups would be impacted by decisions made by the Board and, where possible, set out how this can be mitigated.
The completion of an Equality Impact Assessment (EIA) is an evidence-based approach, designed to help the Trust ensure that policies, practices, events and decision-making processes are fair and do not present barriers to participation or disadvantage any groups, with protected characteristics, from participating. EIAs are required to be carried out at the beginning of any project/programme and ahead of the decision-making process to allow engagement with relevant groups. This is an essential element of the Boards decision making process and demonstrates compliance with the Public Sector Equality Duty.
The Corporate Governance Team support this work through the use of report templates and ensuring policy authors have engaged with the Inclusion Team in relation to completing an EIAs to accompany policies and strategies.
Risks are discussed: both the broader aspects of approaches and the impact on individual groups.

Rating: 2

Owner (Dept/Lead): Corporate Governance Team

Outcome 3C: Board members and system leaders (Band 9 and VSM) ensure levers are in place to manage performance and monitor progress with staff and patients Evidence for this outcome was provided by the Corporate Governance Team Engagement Team.

A summary of the evidence is presented below with the detailed version available on pages 24 – 26 of the Evidence Pack.
There are a number of mechanisms for the Board to manage performance and monitor progress which include:

Equality, Diversity and Inclusion Annual Report: The report shows progress and updates on the EDI priorities, around attraction, recruitment and progression, developing a culturally competent organisation and addresses health inequalities. It also provides an overview of the statutory regulatory data reporting including WRES, WDES, delivery of community and patient engagement and the work of the Staff Networks who make a positive contribution to the culture of the organisation.

Regulatory and Statutory EDI Workforce Report presented to Resources Committee: Sets out annual Workforce Race Equality Standard, Workforce Disability Equality Standard and Gender Pay Gap data. Also included ongoing actions to address inequalities within the workplace.

Diversity and Inclusion Sub Committee: Provides assurance to Resources Committee and Quality Performance Committee on the progress of its work through the Chairs Assurance Report.

Workforce Indicator Report to Resources Committee: Provides bi-monthly assurance against sickness levels; mandatory training and performance against targets; appraisal completion rates against targets, turnover; vacancy position; casework; disciplinaries.

Rating: 2

Owner (Dept/Lead): Corporate Governance Team

Third-party involvement in Domain 3 rating and review

Trade Union Rep(s): Harun Gulab

Independent Evaluator(s)/Peer Reviewer(s): Graham Pacey (F2SU Guardian) Karen Jobson (chaplain for staff wellbeing)

EDS Organisation Rating (overall rating)

Domain 1: 7
Domain 2: 7
Domain 3: 6

Organisation name(s): North West Ambulance Service: 20 out of 44 (Developing)

EDS Action Plan

EDS Lead:
Usman Nawaz – Head of Inclusion & Engagement
Wasim Mir – Equality, Diversity & Inclusion Advisor

Years Active: 2023/24

Authorisation date: 23/02/2024

EDS Sponsor: Lisa Ward – Director of People

Domain 1: Commissioned or provided services

1A: Patients (service users) have required levels of access to the service

Objective: Ensure barriers to access high quality services are addressed and removed by instituting effective communications tools.

Action: Mitigate the risks for those who may struggle with verbal communication. Consider the impacts of triage systems (nationally mandated) on particular protected characteristics groups when being developed.

Completion Date: March 2025

1B: Individual patients (service users) health needs are met

Objective: Improve the ability of the Trust to effectively respond to the needs of service users through engagement and consultation.

Action: Recognise the Hidden Disabilities Sunflower Scheme, gain an understanding of what a hidden disability is and be confident to approach and support all people who are wearing a hidden disabilities sunflower product. Update of the Faith & Culture Card with insights from staff including also insights from the Religion, Belief & Culture forum.

Completion Date: March 2025

1C: When patients (service users) use the service, they are free from harm

Objective: Develop safety improvement plans for thematic reviews for PSIRF local and national priorities.

Action: Establish a NWAS-platform for sharing learning and improvement relating to patient safety, which allows the discussions of cases relating to health inequalities. Continue to monitor the protected characteristics of staff who raise concerns via the Freedom to speak up guardians and work alongside the networks to ensure all staff can raise concerns about patient inequalities.

Completion Date: March 2025

1D: Patients (service users) report positive experiences of the service

Objective: Establish effective processes for recording complaints and compliments with protected characteristics data.

Action: Further empower PPP Patient Safety Partners encourage service users to speak up about any concerns they have which in turn enables better patient experiences.

Completion Date: March 2025

Domain 2: Workforce health and well

2A: When at work, staff are provided with support to manage obesity, diabetes, asthma, COPD and mental health conditions

Objective: Establish mechanisms and processes to support the equality monitoring of people accessing wellbeing services. Ensure the wellbeing offer is dynamic and continues to meet the diverse needs of staff.

Action: Establish mechanisms and processes to support the equality monitoring of people accessing wellbeing services. Ensure the wellbeing offer is dynamic and continues to meet the diverse needs of staff.

Completion Date: October 2024

2B: When at work, staff are free from abuse, harassment, bullying and physical violence from any source

Objective: Establish mechanisms and processes to ensure the effective collation of equality monitoring data relating to staff who have negative experiences.

Action: Develop a plan to increase the reporting of negative experiences. Ensure data collation forms ask about equality monitoring questions. Further engage all Staff Networks to understand staff experiences.

Completion Date: October 2024

2C: Staff have access to independent support and advice when suffering from stress, abuse, bullying harassment and physical violence from any source

Objective: Ensure the independent support avenues adequately meet the diverse needs of staff.

Action: Identify additional channels of internal and external support for staff. Collate regular feedback on the effectiveness of the support avenues.

Completion Date: October 2024

2D: Staff recommend the organisation as a place to work and receive treatment

Objective: Identify additional channels of internal and external support for staff. Collate regular feedback on the effectiveness of the support avenues.

Action: Increase representation of staff in the annual and quarterly staff surveys. Effectively use exit interview data to drive positive changes. Proactively promote development opportunities to staff, particularly to support greater diverse representation in leadership positions

Completion Date: October 2024

Domain 3: Inclusive leadership

3A: Board members, system leaders (Band 9 and VSM) and those with line management responsibilities routinely demonstrate their understanding of, and commitment to, equality and health inequalities

3B: Board/Committee papers (including minutes) identify equality and health inequalities related impacts and risks and how they will be mitigated and managed

3C: Board members and system leaders (Band 9 and VSM) ensure levers are in place to manage performance and monitor progress with staff and patients

Objective: Further enhance the knowledge and awareness of the Board in relation to the EDI agendas, with a specific focus on: addressing health inequalities, and developing an anti-racist organisation. Continue to build on relationships with Staff Networks and Reverse Mentors.

Action: Identify trust lead for health inequalities. Board development with regards the NW Bame Assembly Anti-racist Framework. Develop a framework for a Reciprocal Mentoring Programme, building on the success of the Reverse Mentoring programme.

Completion Date: October 2024

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